A mental health nurse is caring for a newly admitted client with obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?
Instruct the client on relaxation techniques for use when anxiety level increases.
Discuss many alternative coping strategies with the client.
Identify precipitating factors for ritualistic behaviors.
Provide a highly structured activity schedule for the client.
The Correct Answer is C
Choice A rationale: Instructing the client on relaxation techniques for use when anxiety level increases is a beneficial intervention for a client with OCD. However, it is not the first action the nurse should take. The nurse needs to understand the client’s condition, including the triggers for their ritualistic behaviors, before they can effectively guide the client in managing their anxiety.
Choice B rationale: Discussing many alternative coping strategies with the client is an important part of OCD management. However, this should come after understanding the client’s condition and the triggers for their ritualistic behaviors. Without this understanding, the coping strategies suggested may not be effective or relevant.
Choice C rationale: Identifying precipitating factors for ritualistic behaviors is the first action the nurse should take. Understanding what triggers the client’s OCD behaviors is crucial in developing an effective care plan. This understanding allows the nurse to work with the client to develop strategies to manage their triggers and reduce the frequency and intensity of their OCD behaviors.
Choice D rationale: Providing a highly structured activity schedule for the client can be helpful in managing OCD. However, this should not be the first action. The nurse needs to first understand the client’s condition, including the triggers for their ritualistic behaviors. This understanding will allow the nurse to develop a schedule that takes into account the client’s triggers and incorporates effective coping strategies.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
The correct answer/s is Choice/s.
Choice A rationale: Requesting to decrease the dose of oral glycemic medication might not be the most appropriate action for the nurse to take. The client reports overeating since they were 14 years old, which could potentially lead to obesity and related health issues such as type 2 diabetes. However, without more information about the client’s current health status and blood glucose levels, it’s not clear whether a decrease in oral glycemic medication is warranted. It’s important for healthcare providers to monitor and adjust medication dosages based on individual patient needs and responses.
Choice B rationale: Encouraging the client to eat small, frequent meals could be a beneficial strategy. Overeating can lead to weight gain and related health problems. Eating smaller meals more frequently throughout the day can help to control hunger and manage portion sizes, which could potentially help the client to reduce overeating.
Choice C rationale: Instructing the client to weigh themselves daily might not be the best approach. While it’s important for individuals to be aware of their weight as part of overall health management, daily weighing can become a source of stress and anxiety. It might be more helpful to focus on promoting healthy behaviors and coping strategies to manage overeating.
Choice D rationale: Anticipating a potassium supplement for the client might not be necessary. While potassium is an essential nutrient, there’s no indication from the information provided that the client has a potassium deficiency. Overeating does not necessarily lead to nutrient deficiencies, and supplementation should be based on individual needs and medical advice.
Choice E rationale: Teaching the client to plan meals ahead could be a very helpful strategy. Meal planning can help individuals manage portion sizes, ensure a balanced diet, and avoid impulsive eating decisions. This could potentially help the client manage their overeating.
Choice F rationale: Recommending that the client journal about their feelings could be a beneficial strategy. Emotional eating, or eating in response to feelings rather than hunger, is a common issue. Journaling can help individuals identify emotional triggers for overeating and develop healthier coping strategies.
Correct Answer is ["A","B","C","D","E"]
Explanation
: The correct answer/s is Choice/s.
Choice A rationale: Phosphate level is a crucial indicator of the body’s electrolyte balance. In patients with anorexia nervosa, phosphate levels can be significantly affected due to malnutrition and the body’s metabolic response to starvation. Low phosphate levels, known as hypophosphatemia, can lead to serious complications such as muscle weakness, neurological dysfunction, and potentially life-threatening cardiac issues.
Choice B rationale: Capillary refill is a quick test performed on a patient to assess the adequacy of peripheral circulation. The time taken for color to return to an external capillary bed after pressure has been applied to cause blanching signifies the status of the patient’s peripheral blood circulation. Delayed capillary refill time may indicate shock or dehydration, which could be a concern in a patient with anorexia nervosa who may be dehydrated or malnourished.
Choice C rationale: Sodium level is another important electrolyte that needs to be monitored. Patients with anorexia nervosa can have abnormal sodium levels due to various factors such as vomiting, use of diuretics, or not consuming enough dietary sodium. Both high sodium (hypernatremia) and low sodium (hyponatremia) levels can lead to severe neurological symptoms and are considered medical emergencies.
Choice D rationale: Magnesium level is also an important consideration in patients with anorexia nervosa. Low magnesium levels, or hypomagnesemia, can occur due to inadequate dietary intake or excessive loss from the gastrointestinal tract, which can be seen in conditions like anorexia nervosa. Hypomagnesemia can lead to symptoms such as muscle cramps, seizures, and even cardiac arrhythmias.
Choice E rationale: Glucose level is a key indicator of a person’s metabolic state and energy balance. In patients with anorexia nervosa, glucose levels can be low due to inadequate food intake. Hypoglycemia, or low blood sugar, can lead to symptoms such as weakness, tremors, confusion, and in severe cases, it can be life-threatening.
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